In the case below, I discuss constipation management and how to reduce polypharmacy by targeting medications that cause this adverse effect.
KE is a 77-year-old male with a history of GERD, pruritis, insomnia, low back pain, and recent knee replacement. Constipation has been a major problem for this patient and he is taking numerous laxative medications to try to manage it. Current medications include;
- Aspirin 81 mg daily
- Hydroxyzine 50 mg QID
- Oxycodone 5 mg QID
- Prevacid 30 mg daily
- Famotidine 20 mg daily
- Acetaminophen 650 mg PRN
- Diphenhydramine 50 mg HS
- Melatonin 3 mg HS PRN
- Senna S 2 tablets twice daily
- Miralax 17 gm once daily
- MOM 30 mls twice daily PRN
In this case, this patient is requiring numerous medications for constipation management. This is likely due to the anticholinergic and opioid medications. Addressing these and attempting to reduce these would be my primary way to try to reduce adverse effects and improve constipation symptoms. Hydroxyzine is likely being used for itching in this case scenario. I would ideally like to try to reduce that medication to 25 mg four times daily initially and monitor itching symptoms. It would also be important to reassess if the itching is due to adverse effects or new medical conditions.
A couple of other considerations I would look at is using topical agents to help with pruritus. If it is fairly localized, this may be an option to help improve those symptoms. Transitioning to a second-generation antihistamine like cetirizine is also an option.
Next, I would likely review insomnia. Diphenhydramine is likely being used for this but being a first-generation antihistamine like hydroxyzine, it could help with itching as well. Reducing that dose to 25 mg at bedtime is also a consideration and the patient can use their melatonin as needed if that helps their sleep.
Pain management also needs to be addressed in relation to constipation management. I can’t recall where I heard it, but I remember an expert saying that every opioid should have an exit strategy. Tapering and reducing the oxycodone would be appropriate to review. This should significantly help alleviate constipation. A few years back, I laid out some strategies on opioid tapering to help approach this issue with patients.
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